Provider Demographics
NPI:1659100352
Name:SMITH, NICKCO RASHWAN
Entity type:Individual
Prefix:MRS
First Name:NICKCO
Middle Name:RASHWAN
Last Name:SMITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:917 NORWOOD CT
Mailing Address - Street 2:
Mailing Address - City:RAYMORE
Mailing Address - State:MO
Mailing Address - Zip Code:64083-9036
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:917 NORWOOD CT
Practice Address - Street 2:
Practice Address - City:RAYMORE
Practice Address - State:MO
Practice Address - Zip Code:64083-9036
Practice Address - Country:US
Practice Address - Phone:913-907-5782
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-31
Last Update Date:2024-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171W00000XOther Service ProvidersContractorGroup - Single Specialty